2025 Poster Presentations
P084: RECONSTRUCTION OF CLIVAL DEFECTS USING VASCULARIZED FREE AND PEDICLED FLAPS: SYSTEMATIC REVIEW AND PROPOSED ALGORITHMS
Michael J. Marino, MD; Nitish Kumar, MBBS, MS; Devyani Lal, MD; Lisa Marks, MLS, AHIP; Pedro L Gomes, MD; Mayo Clinic in Arizona
Background: Reconstruction of large clivus is one of the most challenging problems faced by skull base surgeons. We conducted a systematic review to elucidate state-of-the-art techniques in clival reconstruction.
Methodology: The following databases were searched in July 2024: Ovid Medline (1946 to present), Ovid Embase (1988 to present), Scopus (2004 to present), and Web of Science (1975 to present). MeSH (Medical Subject Headings) terms included: Cranial Fossa, Posterior; Free Tissue Flaps; Surgical Flaps. Keywords used included: clivus; clival defect*; reconstruct*; and free flap* (* indicates truncation of the word or phrase).
Results: The search returned 153 references of which 21 studies were included for final review. Free flaps for clival reconstruction were reported in 11 studies (8 case reports; 3 case series). These included 18 patients, and all were successfully repaired. Radial artery free flap was used in 9 patients of whom 6 had received prior radiotherapy and 5 had osteoradionecrosis. Transmaxillary route was preferred for pedicle transposition and facial vessels were preferred for vascular anastomosis. Anterolateral thigh flap was used in 7 patients, all of whom had received prior radiotherapy and 1 had clival osteoradionecrosis. In these subjects, parapharyngeal route was preferred for pedicle transposition, and facial vessels were preferred for vascular anastomosis. Vastus lateralis flap was used successfully in a chordoma patient with clival osteoradionecrosis and the anterior serratus muscle flap was used successfully in a patient with granulomatosis with polyangiitis. Use of pedicled flaps was reported in 11 studies with 51 patients, with a reported success rate of 86.2% as 7 patients failed repair. The nasoseptal flap was used in 25 patients with 1 failed repair. Chondrosarcoma was the most common pathology followed by chordoma in this group. Temporoparietal fascia flap was used in 13 patients with a 100% success rate. Chordoma and nasopharyngeal carcinoma were the most common pathologies in this group. Extracranial pericranial flap was used in 7 patients of which 3 had a postoperative CSF leak (57.1% success rate). All patients had clival chordoma of which 4 had prior radiotherapy. This was the only flap reported for use in the pediatric age group. Posterior pedicled inferior turbinate flap was used in 4 patients of which 1 failed repair with a postoperative CSF leak. Use of middle turbinate flap was reported in 3 patients with 1 failed reconstruction. Lateral nasal wall flap was used successfully in 3 patients who received prior radiotherapy. Palatal flap and nasal floor flap were successfully used in 2 patients each.
Conclusion: A variety of free as well as pedicled flaps have been reported in the literature for clival reconstruction with considerable success. The type of defect, preoperative radiotherapy, age of the patient, as well as access to neck vessels, impact the selection of flap in the reconstruction of complex and large clival defects. Close partnership with head and neck reconstructive surgeons is key to success in managing lesions where large clival defects are anticipated, especially in post-radiation settings.